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Reducing pain and swelling
A review of how to reduce the pain and swelling associated with deep-vein thrombosis (DVT)

Introduction
A dual approach: compression and early mobilization
Additional clinical effects
Key points

Introduction

Pain and swelling in the affected limb are among the most common and debilitating symptoms of deep-vein thrombosis (DVT). On diagnosis, a patient will often be given specific treatment to relieve these symptoms, as well as anticoagulant therapy to tackle the underlying blood clot. There is growing evidence that mechanical forms of treatment such as compression garments, worn by patients who also keep mobile (if appropriate), can help reduce pain and swelling as well as slow clot progression. This approach can also have beneficial longer-term effects such as helping to prevent the development of post-thrombotic syndrome.

A dual approach: compression and early mobilization
Compression garments come in a variety of forms, including inelastic bandages, elastic graduated compression stockings, and pneumatic compression gear. Elastic graduated compression stockings typically exert maximum pressure at the ankles and less pressure above, while pneumatic compression consists of a plastic boot or stocking that is intermittently filled with air to squeeze the foot or leg. All of these methods act by forcing blood from vessels near the skin surface into the deep vein system, improving blood circulation in the affected limb and the flow of blood back to the heart. (As an aside, compression garments can sometimes become uncomfortable to wear in hot weather: care should be taken to keep cool.)

Study findings consistently suggest that pain and swelling can be reduced by wearing compression garments and keeping mobile (for example by taking walks) immediately after DVT has been diagnosed. Short-term comparisons between different groups of patients with proximal DVT occurring between the groin and the knee revealed that pain and swelling improved significantly faster in those wearing compression bandages or stockings and who were mobile, than in those resting in bed without any compression.

Is this early mobilization safe? Traditionally, patients diagnosed with DVT were admitted to hospital and advised to rest in bed while they were given intravenous injections of anticoagulant therapy. There were concerns that any strenuous movement might dislodge the clot, or part of it, and cause it to travel to the lungs, causing a potentially life-threatening pulmonary embolism (PE). However, these concerns have proven to be largely unfounded, as studies of selected patients have shown that early mobilization, with compression therapy, does not increase the likelihood of developing PE. This information, together with the recent introduction of low-molecular-weight heparins (anticoagulant therapy that is given subcutaneously and is suitable for home treatment), has resulted in a major shift away from the traditional form of management.

It is important to understand, however, that many factors influence whether early mobilization is appropriate for an individual patient (see the article Mobility and exercise after deep-vein thrombosis for more details). No one should attempt any kind of activity after DVT without first discussing it with their treating physician.

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Additional clinical effects
Compression and early mobilization have important benefits, as well as reducing pain and swelling. Clot progression (an increase in the size of the clot) has been found to be much less frequent and less pronounced in mobile patients using compression bandages or stockings, compared with patients resting in bed without compression.

There are also beneficial effects in relation to post-thrombotic syndrome. This is a long-term complication of DVT characterized by pain, swelling, and skin changes in the affected limb. Generally, about 1 in every 3 people who have had a DVT will develop some post-thrombotic symptoms within 5 years, and usually within the first 2 years. Studies have found that the long-term use of elastic compression stockings, for at least 2 years beginning immediately after a DVT, can reduce the occurrence of post-thrombotic syndrome by about half. A recent review of the available evidence concluded by recommending that "elastic compression stockings should be added to the treatment of DVT to prevent the development of post-thrombotic syndrome." In patients with established post-thrombotic syndrome, elastic compression garments (pressure 30–40 mm) have been found to reduce pain and swelling. Pneumatic compression applied intermittently for 2–4 hours a day, in conjunction with elastic compression, has also been shown to improve symptoms in patients who gained little benefit from elastic compression alone.

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Key points